ࡱ>  Bbjbjdd 4<jj"DD==8lE$[Gi(]]]FGGGGGGILG];;"]]G==G)))]R==8F)]F))A0uhE@anC$F+G0[G(C@1MyX1MHhEhE&1ME\]])]]]]]GGX]]][G]]]]1M]]]]]]]]]D :  鶹ƵAPK requires all F-1 international students to have health insurance due to the complexities and expense of healthcare in the U.S. 鶹ƵAPK provides this mandatory health insurance policy through LewerMark. More information on the coverage and policy is found at  HYPERLINK "http://www.marian.edu/InternationalInsurance" www.marian.edu/InternationalInsurance. Students who have alternative insurance coverage may submit an Insurance Waiver Request Form to be reviewed by GEO. A plan provided by your home countrys embassy or a family member working for a U.S. employer with insurance would be eligible. Waivers are not acceptable for individual plans purchased in the United States or abroad. To petition for a waiver, students must follow the procedures outlined below. The deadline to submit a waiver for the fall is August 1. The waiver is valid for the fall academic term only, unless the alternative insurance plan has an end date to a future academic term. The deadline to submit a waiver for the spring semester is December 1. Additionally, adjustments to alternative plans or the purchasing of a different plan require a new waiver. Each semester, 鶹ƵAPK will place health insurance charges on international students accounts. For questions, please email Rhonda J. Hinkle in the Global Engagement Office ( HYPERLINK "mailto:rhinkle@marian.edu" rhinkle@marian.edu). Waiver Procedure: The staff will review an insurance waiver request which includes a (1) completed Waiver Request Form, (2) copy of alternative insurance card, (3) written proof of alternative insurance which includes a Certificate of Coverage or a copy of the insurance policy. A decision to grant a waiver will be determined within one week after the waiver is received. Waiver request decisions are final. Students who receive a waiver will be notified by email and will have the insurance charge removed from their student account. Alternative Insurance Policy: Along with this form, you must provide written proof that the alternative insurance policy meets the following coverage requirements to have a waiver request accepted. The alternative policy or Certification of Coverage must include the following: Be written in English (to allow for review of the plan) Maximum benefit per injury or sickness of at least $500,000 (USD) Deductible of $500 (USD) or less per accident/illness per year Repatriation coverage of at least $25,000 (USD)* Medical evacuation coverage of at least $50,000 (USD)* No daily cap on a hospital stay Coverage dates no less than August 1 to December 31 for a fall-only waiver, August 1 to May 31 for a fall and spring semester waiver, and August 1 to July 1 for a full year waiver. * If your alternative plan includes all the above but does not have the necessary repatriation and evacuation coverage, you may purchase an insurance rider in order to meet the waiver requirements. PLEASE PRINT OR TYPE THE FOLLOWING INFORMATION I am requesting a waiver from the 鶹ƵAPK Student Insurance for the following term(s) and will submit documentation reflecting the following dates: Fall semester waiver request Fall and Spring waiver request Fall, Spring, and Summer waiver request Students Last Name: __________________________________First Name: ____________________________ Student Email Address: ____________________________ Local Phone Number: ________________________ Reason for waiver request (select one): My parent or spouse is living/working in the United States and has medical insurance coverage for me. I am a sponsored student and have medical insurance coverage from my sponsoring agency. I understand that: A denied waiver request OR failure to provide complete and accurate information by the waiver deadline will result in my automatic enrollment in 鶹ƵAPK international student plan. If my insurance coverage ends for any reason, it is my responsibility to notify the school. I have the option of having the 鶹ƵAPK Student Insurance Plan, but I am choosing to use an alternative plan should my waiver be approved. Any medical expenses I incur in excess of my insurance coverage are my responsibility and 鶹ƵAPK assumes no liability. Signature: __________________________________________ Date: ______________________      Insurance Waiver Request Form !"#$1;>BS^ Z [    zqzqhN{u5OJQJh;hN{u5OJQJhu\OJQJhQ7OJQJhwOJQJh,hPaK0JOJQJjhPaKOJQJUhPaKOJQJhuOJQJhBOJQJhN{uOJQJhCah^6<OJQJhCahOJQJhCahCaOJQJhlvOJQJ, ! "  *+ 7$8$H$gdZ8 & F7$8$H$gdZ8 & F7$8$H$gd+ & F7$8$H$gd+ 7$8$H$gdu 7$8$H$gdN{ugdPaKgdN{ugd ! ' Z y   ! " . 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